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The Association Between the Low Muscle Mass and Osteoporosis in Elderly Korean People

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The Association Between the Low Muscle Mass and Osteoporosis in Elderly Korean People ORIGINAL ARTICLE Musculoskeletal Disorders http://dx.doi.org/10.3346/jkms.2014.29.7.995 • J Korean Med Sci 2014; 29: 995-1000 The Association between the Low Muscle Mass and Osteoporosis in Elderly Korean People Sunyoung Kim,1,2 Chang Won Won,1 The purpose of this study was to predict osteoporosis risk as decreasing muscle mass and to Byung Sung Kim,1 Hyun Rim Choi,1 declare the cut-off value of low muscle mass in an elderly Korean population. This study and Min Young Moon1 was based on data from the 2008-2010 Korea National Health and Nutritional Examination Surveys (KNHANES). The subjects included 1,308 men and 1,171 women over 65 yr. Bone 1Department of Family Medicine, College of Medicine, Kyung Hee University, Seoul; 2Department mineral density (BMD) and appendicular skeletal muscle (ASM) were measured by dual of Medicine, Graduate School Ewha Womans energy X-ray absorptiometry (DXA), and appendicular skeletal muscle was adjusted by University, Seoul, Korea height as a marker of sarcopenia. After confirming the correlation between low muscle mass and BMD, the best cut-off value of muscle mass to estimate osteoporosis was Received: 23 December 2013 Accepted: 24 April 2014 suggested through the receiver operating characteristic (ROC) curve. For both men and women, BMD correlated positively with low muscle mass when ASM/Ht2 was used as a Address for Correspondence: marker for sarcopenia. The ROC curve showed that ASM/Ht2 was the best marker for Chang Won Won, MD osteoporosis at a cut-off value of 6.85 kg/m2 for men and 5.96 kg/m2 for women. When Department of Family Medicine, Kyung Hee University Hospital, 23 Kyunghee dae-ro, Dongdaemun-gu, Seoul 130-872, Korea these cut-off values were used to determine sarcopenia, the risk of osteoporosis increased Tel: +82.2-958-8697, Fax: +82.2-958-8699 4.14 times in men and 1.88 times in women. In particular, men (OR 2.12) with sarcopenia E-mail: [email protected] were more greatly affected than women (OR 1.15), even after adjusting for osteoporosis Funding: There is no research grant or funding with respect to this manuscript. risk factors. In elderly Korean people, sarcopenia is positively correlated with BMD and there is a strong correlation between sarcopenia and osteoporosis with risk of bone fracture. Keywords: Osteoporosis; Sarcopenia; Korea; KNHANES; Elderly Population INTRODUCTION gartner et al. suggested defining sarcopenia based on appen­ dicular skeletal muscle divided by height squared (Ht2) (7). Jans­ According to the 2010 data from the Statistics Korea, the elderly sen et al. used biochemical impedance analysis (BIA) to mea­ population in Korea increased 24.3% from 2005 to 2010, which sure total muscle mass and divided this mass by weight to de­ was 12.2 times greater than the increase in the total population fine sarcopenia (4). In recent studies, sarcopenia is defined as a (2.0%) during the same time period (1, 2). With this significant systemic continuous decrease in skeletal muscle strength and increase in the elderly population, it is important that increas­ muscle mass so that the diagnosis of sarcopenia must be sup­ ing attention be given to help maintain their physical and social ported by decreased muscle mass and functional muscle strength functioning while minimizing chronic disease and disability to (8). Until now, many studies of muscle mass and BMD have enhance their quality of life. been carried out (9­11), and they showed that low muscle mass Decreased muscle mass and bone mineral density are signif­ is correlated with low BMD. Unfortunately, their study popula­ icant changes that occur with aging, and these are often associ­ tions were inconsistent and their definitions of sarcopenia dif­ ated with an inability to adapt to external stress resulting in falls, ferent. In our study, by presenting a cut­off value of the muscle trauma, functional disability, increased hospitalization, decreas­ loss that can predict osteoporosis in Korean elderly individuals, ed quality of life, and increased mortality (3­5). Thus, diagnos­ we attempted to identify the relationship between muscle loss ing osteoporosis and sarcopenia is not only important clinical­ and osteoporosis. ly, but also has significant public and social ramifications. De­ termining the relationship between osteoporosis and sarcope­ MATERIALS AND METHODS nia may help maintain musculoskeletal function and prevent fractures associated with accidental falls. Subjects The diagnostic criteria have already been established for os­ This study is based on data obtained in the second and third teoporosis (5), but there is still controversy regarding the diag­ years (2008­2009) of the Korea National Health and Nutritional nostic criteria and markers for sarcopenia. Early studies by Baum­ Examination Survey (KNHANES) IV and the first year (2010) of © 2014 The Korean Academy of Medical Sciences. pISSN 1011-8934 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. eISSN 1598-6357 Kim S, et al. • Sarcopenia and Osteoporosis the KNHANES V (2). The KNHANES is a cross­sectional study samples were collected during the health examination survey. and has been conducted periodically since 1998 to assess the These samples, taken from the antecubital veins, were refriger­ health and nutritional status of the civilian non­institutional­ ated immediately and transported on dry ice to the designated ized population of Korea and has generated nationwide and central testing facility, and were analyzed within 24 hr of sam­ representative statistical data by self­administered question­ pling. Serum 25(OH)D levels were measured using a gamma naires on health status, health behaviors, and nutritional status. counter (1470 Wizard, Perkin­Elmer, Turku, Finland) with a ra­ Data was collected via household units and selected based on a dioimmunoassay (RIA) kit (DiaSorin, Stillwater, MN, USA) (2). stratified, multistage probability sampling design. The selection was made from sampling units based on the geographical area, Statistical analysis gender, and age using household registries. The details of the All data are presented as the mean ± standard error (SE) for the KNHANES IV and V have been previously described (12, 13). A continuous variables or as proportion (SE) for the categorical total of 4,772 individuals aged ≥ 65 yr participated. Of the 4,772 variables. The characteristics of the participants were compared participants, we excluded individuals who did not have DXA according to sex using independent sample Student’s t­tests for results (n = 1,452) and those with a history of stroke, coronary the continuous measures and Rao scatt chi­square tests for the artery disease, thyroid disease, lung disease, liver and renal dis­ categorical measures. Regression analysis was applied to assess ease, and any cancers and those taking medications likely to af­ the association between various parts of the BMDs and the two fect bone or soft tissue metabolism, such as thyroid hormone, indexes of low muscle mass. The receiver operating character­ bisphosphonates, SERM, or weight controlling drugs (n = 841). istic (ROC) curve analysis was performed to determine the best The exclusion criteria were aimed to ensure selection of healthy cut­off value of low muscle mass for indicating osteoporosis. participants and to minimize the confounding effects on mus­ The areas under the ROC curve (AUC) were investigated for os­ cle mass. The present study included 2,479 elderly participants teoporosis. The ROC curve was a graph of sensitivity plotted (1,308 men and 1,171 women). against (1­specificity) over all possible diagnostic cut­off values. The optimal cut­off values were obtained from the maximal Measurement of bone density and appendicular skeletal Youden’s index, calculated as (sensitivity+specificity­1) and the muscle mass best combination of sensitivity and specificity. The odds ratios All participants underwent the DXA (DISCOVERY­W fan­beam (ORs) and 95% confidence intervals (CIs) were calculated by densitometer; Hologic Inc., MA, USA) for assessment of BMD logistic analysis to confirm the impact of low muscle mass, which and body composition. Standardized daily quality control of was based on the cut­off value for osteoporosis, after making these DXA in instruments was performed using spine phantom adjustments for age, fat mass, calcium intake, vitamin D status, provided by the manufacturer before the study commenced. smoking, alcohol consumption, and physical activity. Statistical The BMD (g/cm2 or T­score) of the whole body, femoral neck, analyses were performed using the survey procedure of SAS and lumbar spine (L1­4) were analyzed. The diagnosis of osteo­ software (version 9.2; SAS Institute, Cary, NC, USA) to account porosis was made using the WHO T­score criteria (T­score < ­2.5), for the complex sampling design and to provide nationally rep­ and the maximum BMD value for Japanese patients was used resentative prevalence estimates. P < 0.05 was considered sta­ as a reference due to the lack of established diagnostic criteria tistically significant. for Koreans (14, 15). Appendicular skeletal muscle (ASM) mass was calculated as the sum of muscle mass in arms and legs, as­ Ethics statement suming that all non­fat and non­bone tissue is skeletal muscle This study was approved by the institutional review board of (16). According to the definition proposed in previous studies, KyungHee University Hospital, in Seoul, Korea (approval ID: we used muscle mass indexes, the height adjusted ASM (ASM/ KMCIRB 1413­05). Informed consent was waived by the board. Ht2, kg/m2) (5, 7, 17). RESULTS Anthropometric and laboratory measurements Body weight and height were measured to the nearest 0.1 kg The study population comprised 1,308 men and 1,171 women and 0.1 cm, respectively.
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